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# Tranexamic Acid
## Overview
Tranexamic acid (TXA) is a synthetic lysine analog that acts as an antifibrinolytic agent. It competitively inhibits the activation of plasminogen to plasmin, thereby preventing the breakdown of fibrin clots.
## Primary Indications
* **Hemorrhage:** Traumatic hemorrhage (CRASH-2 protocol), postpartum hemorrhage, perioperative blood loss reduction.
* **Hyperfibrinolysis:** Heavy menstrual bleeding, epistaxis, dental surgery in patients with coagulopathies.
* **Hereditary Angioedema:** Short-term prevention of attacks.
## Adult Dosing
* **Trauma:** 1 g IV bolus over 10 minutes, followed by 1 g IV infusion over 8 hours. Administer as soon as possible, ideally within 3 hours of injury.
* **Heavy Menstrual Bleeding:** 1,300 mg orally three times daily for up to 5 days during menstruation.
* **Perioperative/Surgical:** Protocol-dependent; typically 10–100 mg/kg IV or topical application depending on the surgical site and procedure.
## Pediatric Dosing
* **Trauma:** 15 mg/kg (max 1 g) IV bolus, followed by 2 mg/kg/hour infusion for up to 8 hours.
* **Dental/Surgical (Off-label):** 10–25 mg/kg orally two to three times daily. Consult pediatric-specific guidelines or institutional protocols for elective procedures.
## Dose Adjustments
* **Renal Impairment:** Requires reduction in patients with CrCl < 50 mL/min.
* CrCl 30–50 mL/min: Reduce dose by 50% or increase dosing interval.
* CrCl < 30 mL/min: Significant caution; consider 10–25% of standard dose or monitor plasma concentrations.
* **Hepatic Impairment:** Generally no dose adjustment required due to minimal metabolism.
## Contraindications
* **Active Thromboembolic Disease:** History or high risk of DVT, pulmonary embolism, or cerebral thrombosis.
* **Color Vision Defects:** Concomitant use with contraindicated due to potential for ocular toxicity.
* **Subarachnoid Hemorrhage:** Risk of cerebral edema or infarction.
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, abdominal pain.
* **Serious:** Thromboembolic events (PE, DVT, MI, stroke), seizures (especially with high IV doses or rapid infusion), allergic reactions (anaphylaxis), and visual disturbances.
## Key Drug Interactions
* **Thrombolytics/Factor Concentrates:** Concomitant use with factor IX complex or anti-inhibitor coagulant concentrates may increase risk of thrombosis; avoid combined use.
* **Hormonal Contraceptives:** Potential increased risk of thrombosis if taken with estrogen-containing products.
## Monitoring
* **Vitals:** Blood pressure and heart rate during IV administration.
* **Signs of Thrombosis:** Monitor for leg swelling, chest pain, dyspnea, or neurological deficits.
* **Renal Function:** Monitor renal status to adjust dosing appropriately.
* **Visual/Neurological:** Baseline and periodic eye exams if prolonged therapy is required.
## Clinical Pearls
* **Seizure Risk:** Rapid IV bolus administration is associated with an increased risk of seizures; always adhere to recommended infusion rates.
* **Off-Label Utility:** Widely used off-label in emergency medicine and trauma following the CRASH-2 and WOMAN trial results.
* **Topical Use:** Increasingly used topically in orthopedic and cardiac surgery to reduce local site bleeding with lower systemic exposure.
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**Disclaimer:** This information is for educational purposes only. Clinical practice and dosing protocols vary significantly by institution and severity of condition. Always verify current prescribing information, institutional guidelines, and order sets before administration.
